Tetanus

Symptoms Of Tetanus

The most common sign of this infection is tightening of the jaw muscles. Tetanus infection can lead to serious health problems, including being unable to open the mouth and having trouble swallowing and breathing. Other symptoms include:

• Jaw cramping
• Sudden, involuntary muscle spasms often in the stomach
• Painful muscle stiffness all over the body
• Trouble swallowing
• Seizures (jerking or staring)
• Headache
• Fever and sweating
• Changes in blood pressure and heart rate

Causes Of Tetanus

Tetanus is caused by a toxin produced by Clostridium tetani bacteria spores found in dust, animal feces, and soil. When these spores enter a deep flesh wound, they transform into bacteria that release a lethal toxin known as tetanospasmin.

The toxin damages the muscles, specifically the motor neurons that control muscle function. This causes muscle spasms and stiffness, which is a major symptom of tetanus.

Tetanus cases are frequently seen in people who have never been immunized or in adults who have not received their 10-year booster shot. Tetanus is not a contagious disease and thus cannot be passed from person to person.

Other ways:

Tetanus bacteria can also infect someone’s body through breaks in the skin caused by:

• Clean superficial wounds (when only the topmost layer of skin is scraped off)
• Surgical procedures
• Insect bites
• Dental infections
• Compound fractures (an exposed broken bone)
• Chronic sores and infections
• Intravenous (IV) drug use
• Intramuscular injections (shots given in a muscle)

Types Of Tetanus

Tetanus is a vaccine-preventable disease acquired through environmental exposure to the spores of Clostridium tetani. There are four forms of tetanus, based on clinical findings. They include:

 

1. Generalized tetanus

It is the most prevalent kind (more than 80% of reported cases). Typically, the head and neck muscles are the first to become tight and spastic, with the rest of the body eventually being affected. The full recovery from these spasms may take several months, and they can persist for up to 4 weeks.

2. Localized tetanus

It is an uncommon form of the disease in which patients have persistent contraction of muscles in the same body part as the injury. These contractions could last for several weeks before fading down gradually. 

3. Neonatal tetanus

It is a type of tetanus that manifests within a week of birth in newborn babies. In case the mother is not immune, neonatal tetanus affects newborns who are not protected by their own immune system or antibodies from the mother.

Note:  The newborn should receive human tetanus immunoglobulin (TIG) without delay. Also, it can be prevented by immunizing the mother before or during pregnancy or by ensuring a clean  delivery in a sterile environment..

4. Cerebral tetanus

It is also called cephalic tetanus which involves muscles of the face and larynx. It only affects the head's nerves and muscles. The most frequent cause of cephalic tetanus is head trauma. It is extremely uncommon, making up around 1% to 3% of tetanus cases.

Risk Factors For Tetanus

Tetanus usually occurs in persons who are not immunized, partially immunized, or fully immunized but lack adequate booster doses. The risk factors for neonatal tetanus include the following:

1. Contaminated cuts or wounds 

Tetanus bacteria are more likely to infect certain breaks in the skin through feces (poop), or saliva (spit) and wounds caused by an object, like a nail or needle, breaking the skin.

2. Unvaccinated mother

Vaccination helps protect babies during this time when they are most vulnerable, women should get the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) during each pregnancy.

3. Delivery in contaminated areas

Obstetric tetanus, which occurs during pregnancy or within 6 weeks of the end of pregnancy. It happens following the contamination of wounds with Clostridium tetani spores during pregnancy or the use of contaminated tools during deliveries or abortions.

4. Septic cutting of the umbilical cord

Neonatal tetanus occurs when non sterile instruments are used to cut the umbilical cord or when contaminated material is used to cover the umbilical stump.

5. Family history

A history of neonatal tetanus in a previous child increases the risk for neonatal tetanus in subsequent children.

6. History of immunosuppression

Individuals who are on medications for autoimmune conditions or post-organ transplant have low immunity which can increase their chances of tetanus infections.

7. Sharing contaminated needles 

Skin punctures by contaminated needles (such as those used to inject illegal drugs or to tattoo or do body piercing) can also lead to tetanus.

 

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6. Diabetes

Patients who have diabetes and chronic wounds are more prone to tetanus than the other populations.

Diagnosis Of Tetanus

No confirmatory laboratory testing is available; the diagnosis is made clinically. Other things to help confirm the diagnosis include:

1. History

When there is a history of a prior tetanus-prone injury and insufficient tetanus immunization, tetanus should be suspected in particular. Tetanus can be identified by a patient's recent history of trauma, wounds, scrapes, and punctures as well as by a doctor looking for specific symptoms and indicators.

2. Spatula test

The spatula test is a simple diagnostic test. Touching the throat with a spatula in normal patients elicits a gag reflex and efforts to expel the spatula; a negative result. If tetanus is present, a reflex spasm occurs, and the patient bites the spatula; a positive result.

Prevention Of Tetanus

Vaccination and good wound care are the cornerstones in the prevention of a tetanus infection. They are discussed as follows:

I. Vaccination

The only way to prevent a tetanus infection is by getting vaccinated on time. The tetanus vaccine shot is usually given in the deltoid muscle. The tetanus vaccine is given as part of the following vaccines:

• Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine: Contains full doses of diphtheria, tetanus, and pertussis (whooping cough) vaccines. 

• Diphtheria and tetanus (DT) vaccine

• Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine: Contains a full dose of the tetanus vaccine and a lower dose of diphtheria and whooping cough vaccines.

• Tetanus and diphtheria (Td) vaccine

• Tetanus Toxoid (TT) vaccine

Note: DTaP/DT are only given to babies and children younger than 7 years whereas Tdap/Td/TT are given to adolescents and adults.

Who should take tetanus vaccination and when?

Children

• Children between 2 months to 6 years should get 5 DTaP shots. Three doses at 6, 10 & 14 weeks and two booster doses at 16-24 months and 5-6 years of age respectively.
• Children who had a very bad reaction to DTaP can receive DT vaccine. However, they will not receive any protection against whooping cough.
• Children 11-12 years should get 1 booster shot of Tdap.

Adults 

• Adults over 18 years who did not receive primary immunization, three doses of Td vaccine are indicated. Two doses are administered at least 4 weeks apart, and the third dose is given 6-12 months after the second dose. The Tdap vaccine can substitute any one of the Td doses.
• Adults who have completed their primary vaccination schedule, should get TT or Td shot every 10 years till the age of 65. One dose of Tdap vaccine may be administered in place of Tt/Td vaccine. 

Pregnant women

• The national immunization schedule in India recommends the 2 doses of TT/Td regardless of the immunization status of pregnant women. There should be a minimum gap of 4 weeks between the two doses. Tdap vaccination can also be considered instead of the second dose of TT/Td injection.
• If a mother received 2 TT/Td doses in the last pregnancy and gets pregnant within 3 years then only one booster dose is recommended.

Contraindications of Tetanus vaccination

• History of a severe adverse reaction to any vaccination ingredient.
• If within seven days following vaccination and without apparent explanation, suffered encephalopathy (such as coma, diminished level of consciousness, or persistent seizures).
• History of Guillain-Barré syndrome (GBS)
  
  

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II. Appropriate wound care

You need to take proper care if you get any cut, wound or injury especially if it is contaminated. 

Here are a few tips that you need to follow if you have a minor wound or injury:

1. Control bleeding: Use a clean tissue, piece of gauze, or clean cloth to apply direct pressure to the cut or wound until bleeding stops. To aid in reducing bleeding, try to elevate the arm or leg above the heart if possible. 
   
2. Maintain hygiene: First of all, wash your hands before cleaning and dressing the wound. Once the bleeding has stopped, a saline solution, bottled water, or clear running water should be used to rinse the wound.
   
3. Cover the wound: Use a sterile bandage after using an antibiotic cream to lower the chance of infection. To keep the wound clean and dry, change the bandage frequently as it will keep harmful bacteria out.
   
4. Change the dressing: Replace the bandage at least once every day, or whenever the dressing is soiled or wet, and change the dressing. You can use an antibiotic ointment.
   
5. Manage adverse reactions: If you observe any rash or wound getting worse due to antibiotic use or if you are allergic to the adhesive used in bandages switch to adhesive-free dressings or sterile gauze and paper tape.

Watch this informative video to know more about how to manage wounds efficiently.

Specialists To Visit

The following specialists help to reduce morbidity and mortality associated with tetanus:

• General physician
• Toxicologist
• Neurologist
• Pulmonary medicine specialist
• Anesthesiologist

A toxicologist helps to rule out any poisoning and to determine if any substance is toxic or harmful.

A neurologist is a doctor who treats diseases of nerves and in the case of tetanus, they treat seizures.

A pulmonary medicine specialist can help when there is respiratory compromise and can help with providing ventilation.

An anesthesiologist is to administer drugs, such as baclofen.

When to see a doctor?

• You are not sure about completing your tetanus vaccination schedule.
• You haven't received a tetanus injection in the last ten years.
• Not sure when the last tetanus vaccination was taken.
• You are injured outdoors.
• The wound has been in direct contact with soil.
• The wound has dirt or debris that won’t come out.
• A deep puncture wound, an object in the wound, an animal bite, or a severe cut.
  
  

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Treatment Of Tetanus

Tetanus is a medical emergency and its management comprises the following:

1. Early and aggressive wound debridement

It is advisable to surgically debride any wounds that are present. It's essential to clean your wound with sterile or clean water and an antiseptic solution to get rid of any dirt, debris, or foreign objects that could harbor bacteria. 

Always keep your first aid kit handy in case of an emergency.

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2. Antimicrobial therapy

Although they are always advised, antibiotics probably only have a little part to play in the treatment of tetanus. It is crucial to note that without proper wound debridement, appropriate antibiotic therapy may fall short of eliminating C. tetani.
Drugs used are:

• Metronidazole 
• Penicillin G
• Cefuroxime

3. Human tetanus immune globulin (HTIG)

Neutralization of unbound toxins with Human tetanus immune globulin is given. All patients with suspected tetanus should immediately receive both passive (with TIG) and active (tetanus toxoid–containing vaccines). 

4. Drugs to control muscle spasms

Generalized muscle spasms are life-threatening since they can cause respiratory failure, lead to aspiration, and induce generalized exhaustion in the patient. 

Note: Long-term muscle contractions result in abrupt, strong, and painful muscle group contractions. It's known as tetany. This is called tetany. These are the episodes that can cause fractures and muscle tears.

There are several drugs that may be used to control these spasms which include:

• Benzodiazepines (like diazepam)
• Pancuronium
• Antispasmodics (like baclofen)
• Magnesium sulfate

5. Hospitalization and supportive care

• People with severe tetanus need to stay in an intensive care environment. As sedatives inhibit breathing you might need to stay under ventilation temporarily. 
• Nutritional support should also be initiated early. As the energy demands in tetanus can be extremely high due to repeated spasms, excessive sweating, muscular contractions etc.
• Heparin or any other anticoagulant should be administered early in order to prevent blood clotting in veins.
• Tetanus often begins with mild spasms in the jaw muscles, which eventually can affect your chest, neck, back, and abdominal muscles. Hence, physical therapy is suggested as soon as spasms have stopped.

6. Vaccination during recovery

Tetanus disease does not provide immunity against tetanus. Active immunization should be initiated or continued with a tetanus toxoid-containing vaccine as soon as the person’s condition has stabilized.

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Complications Of Tetanus

Serious health problems that can happen because of tetanus include:

1. Laryngospasm: It is uncontrolled/involuntary tightening of the vocal cords that may lead to interference with breathing. 


2. Fractures: Fractures of the spine or long bones may result from involuntary muscle movements. 


3. Hypertension and/or abnormal heart rhythm: Hyperactivity seen in tetanus may lead to hypertension. It can also cause abnormal heart rhythm. 


4. Nosocomial infections: These are infections that are acquired while getting medical care but were absent at the time of admission. They are also known as healthcare-associated infections (HAI).


5. Pulmonary embolism: It refers to a blood clot that has passed through the bloodstream from another part of the body and blocked the major artery of the lung or one of its branches. 


6. Aspiration pneumonia: It is a lung infection that develops when things like saliva or vomit accidentally go into the lungs. 


7. Death: Tetanus can be fatal in some cases.These mostly include people 60 years of age or older and those who have never received a vaccination.

Alternative Therapies For Tetanus

A few alternative therapies that have shown some promise in the management of tetanus include:

1. Botulinum toxin

Botulinum toxin, also called “miracle poison,” is a neurotoxin produced by the bacterium Clostridium botulinum. Studies show that other than immunization, the administration of this toxin is a treatment approach that has been used in recent years to reduce rigidity and spasms in tetanus patients. 

2. Vitamin C

Research suggests that vitamin C might play an important role in preventing tetanus and reducing mortality. It also acts as an antioxidant, helps wound healing and enhances immunity.

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Living With Tetanus

Tetanus can have various adverse effects on the patient's lifestyle, depending on the severity of the symptoms. The challenge or ease of living with tetanus varies for each survivor, subject to the availability of medical care and rehabilitation opportunities and their family and social support. Various forms of rehabilitation and support include:

• Physical therapy can also be used to help with muscle rigidity and spasms, increase mobility and movement and maximize function and quality of life.
• Cardiopulmonary physical therapy can be used to help in the prevention of respiratory complications.
• Emotional and caretaking are also required by the person dealing with tetanus. A helping hand or support from the family on the emotional ground can do wonders in recovery. 
  
  

Caregivers play a very important role in the overall disease outcome of the patient diagnosed with tetanus. The different roles of the nurse and include the following responsibilities:

• Recording medical information.
• Creating care plans to suit the individual needs of the patient.
• Combative wound care and infection control.
• Providing emotional support so that the patient does not feel alone.